Question:
I am struggling to assist a woman with a newborn, 4 days old who is causing trauma to the nipple. The issue appears to be the infant’s curling upper lip. The baby’s upper labial frenulum is tight and the lip is difficult to uncurl while on breast. Mom’s nipples are small; her breast and areola large. Baby takes best with cigarette type hold on areola. I can get baby in good position, but mom cannot get baby on without pain on top of breast where lip curls in. Mom is coming in today for follow-up after discharge.
Cynthia Sales
Answer:
There is one published case report in the literature describing a situation where a tight labial frenum created nipple pain. (Wiessinger D, Miller M. Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. J Hum Lact 1995; 11(4):313-16.) A tight upper labial (related to the lips) frenum is a known cause of malformation of the teeth. Dentists or orthodontists may sever this tissue to prevent or correct a gap formed between the upper front teeth. We show several photos in The Breastfeeding Atlas of infants and an adult with tight upper labial frena in Chapter 18 (Orofacial Variations).
Tight Labial Frenum (click to enlarge)
Lip retraction is fairly common in newborns, and there can be other reasons for it than a tight upper labial frenum. Lip retraction is often a compensation performed by a baby who can’t keep the nipple in their mouths using normal sucking mechanics. The baby is forced to grip excessively with that rolled-in upper lip. Weak facial tone, thin cheeks, receding chin and tongue-tie are other contributing causes for lip retraction.
In some cases, there is nothing wrong with the baby except that they are weak, not sufficiently recovered from birth and are finding their mom’s breast anatomy to be challenging. The situation requires more observation to see which issues are coming into play before you recommend ablation of the frenum. Of course in the meantime, you need a combination of strategies to manage the mom’s pain and protect breastfeeding until your understanding clarifies.
The reason you can’t pop the lip into a more normally flanged position is because the baby will lose the breast otherwise and resists the maneuver. It is interesting that you can position the baby comfortably using a cigarette hold. It suggests that when the mom or the LC holds the breast more securely, it becomes less necessary for the baby to roll in the lip. That speaks less to the frenum as the problem and makes me more curious about the other issues.
For now, make sure the nipples heal. If the skin is broken, use mild soap and water to cleanse the wounds. If they look inflamed, try a few days of topical antibiotic ointment to prevent infection. If the mom can’t tolerate nursing at every feeding, alternate with a pump to make sure she brings in a robust supply and manages engorgement. Engorgement will worsen this situation because the breast will lose more elasticity.
You might also try a nipple shield: both to protect from pain and to give the baby more nipple to grasp. Use a small-size shield though. You wouldn’t want to put a large shield over such a small nipple.
Try a football position with the baby’s butt seated against the back of the chair and mom’s hand secure at the base of the baby’s head. Lead with the chin and make sure the nose is tipped away. This will jam the chin tight against the breast. Mom will then have a free hand to grasp the areola and push it forward. Holding the nipple forward is what you are doing when you are helping with the latching.
